Symposium Management of the Acute Complications of Diverticular Disease: Acute Perforation
of Colonic Diverticula
WARD O. GRIFW':N, JR., M.D., PH.D.*
A major complication of diverticular disease of the colon is perforation of a single or several diverticula. T h e sequelae of the perforated diverticulum depend on the location and extent of perforation. A diverticulum situated on the antimesenteric border of the large bowel will most often produce free perforation into the peritoneal cavity. A diverticulum at the mesenteric border of the sigmoid colon may produce a localized process if the perforation is promptly contained, or with repeated or large perforations into the mesentery, the picture of bowel obstruction may be seen. When the perforation is free into the peritoneal cavity, there is immediate spillage of fecal material, and the patient usually has acute onset of lower or generalized abdominal pain. There may be no antecedent history suggesting diverticular disease. Depending upon the dtaration of symtoms, the findings will be those of generalized abdominal tenderness with rebound tenderness, at first local but later generalized. Bowel sotmds will be hypoactive or absent. Fever will be present, and an upright fihn of the abdomen may show free air under the diaphragm in approxi-
mately half of the cases. Obviously, the finding of free air under the diaphragm or progression of symptoms will make an exploratory celiotomy mandatory. T h e signs and symptoms associated with perforation into the mcsentery or quickly localized by adherence to the pelvic wall or lateral gutter are entirely different from those associated with free perforation. A small leak into the mesentery may manifest as mild left lower quadrant pain associated with anorexia, so-called "left-sided appendicitis." T h e physical findings are those of left lower quadrant tenderness, perhaps with some rebound tenderness and muscle guarding. Bowel sounds may be perfectly normal. T h e r e is usually some fever, the leukocyte count is elevated slightly, and flat and upright films of the abdomen are unremarkable. These patients frequently respond to bed rest, no oral intake, and systemic antibiotics. T h e y can then be evaluated for colonic disease after the symptoms have subsided. Obviously, if the patient's condition worsens despite this nonoperative therapy, exploration is mandatory. On the other hand, two different clinical pictures are associated with large contained perforations. T h e patient can have tile signs and symptoms of colonic obstruction, with a clear-cut history of several epi-
* D e p a r t m e n t of Surgery, University of Kentucky College of Medicine, Lexington, K e n t u c k y 40506.
293 Dis. Col. & Rect. 3/lay-June, 1976
Volume 19 Number 4
Dis. CoL & Rect. NIay-June, 1976
GRIFFEN
294
sodes of left lower q u a d r a n t pain and intermittent diarrhea and constipation, with a tendency to become more constipated until frank obstruction occurs. T h e r e is nsually left lower q u a d r a n t tenderness, a mass may be palpated, and rectal and sigmoidoscopic examination may demonstrate a lesion. Depending upon the duration of the obstructive symptoms, bowel sounds may be normal, the high-pitched tinkling sounds associated with obstruction, or absent. Little or no fever is present, and the leukocyte count may be normal or only slightly elevated. On the other hand, the patient may have developed a large abscess cavity in association with the perforation and be in an obviously septic condition, with abdominal pain, high spiking fever, a palpable left lower q u a d r a n t mass, and a probable mass on rectal examination. T h e leukocyte count usually is quite elewtted, and abdominal films may show evidence of an abscess. In either instance exploration must be performed. When an exploration is performed under any or the conditions outlined above, the surgeon is really faced with three basic decisions: 1) to drain or not to drain; 2) to divert or not to divert; and 3) to resect or not to resect. T h e m a n a g e m e n t of each patient should be individualized, but there are a n u m b e r of procedures that will suffice in a given situation. However, tile standard three-stage technique of right transverse colostomy for diversion followed by resection of the involved colon and primary anastomosis two, three, or even six months later, and finally closure of tlle transverse colostomy as three separate procedures should be used rarely, if at all. To
Drain
or N o t
to D r a i n
Obviously, if a patient has a localized abscess, it requires thorough and adequate drainage. If at all possible, it is best to provide for such drainage in an extraperitoneal fashion. It may be possible to
drain snch an abscess, particularly when there is pelvic extension, directly through the rectum or, in women, through the posterior fornix of the vagina. Conversely, it is impossible to drain the entire peritoneal cavity, and therefore drains should not be used when there is a free perforation of a diverticulum. W h e t h e r to use drains when a resection and primary anastomosis has been constructed is controversial. My own viewpoint is that under these circumstances drains are rarely necessary. To
D i v e r t or N o t
to D i v e r t
In the case of tile large abscess that requires drainage and in a patient who is quite ill, a quick loop colostomy of the descending or left transverse colon as a diversion may be the procedure of choice.. Diversion using the left colon proximal to tile obstruction 1nay be used in patients who are depleted and quite ill from tim obstructing process. In lnost other instances a proximal colostolny is no longer employed. To
Resect or Not
to R e s e c t
As preoperative preparation ol/ patients has improved, it is now possible in most instances of perforated diverticular disease where exploration is necessary to give the patient sufficient fluids and electrolytes, blood, and antibiotic intravenously so that he can withstand a major operative procedure. Tllerefore, resection is becoming the treatlnent of choice in lnany instances. In tile case of a free perforation, resection with an end-colosto,ny and oversewing of the rectal segment, the so-called " H a r t m a n n procedure," is the correct operation. Silnilarly, when the abscess is localized or there is obstruction without a great deal of abscess formation, resection of the involved segment with an end-colostomy and H a r t m a n n procedure may be utilized satisfactorily. T h e controversy surrounding resection under these circuln-
Volume 19 Number 4
MANAGEMENT
OF D I V E R T I C U L A R
stances is whether a primary anastomosis should be performed at the time of the resection. If there is any time when the patient must be handled individually, it is now, when a decision about primary anastomosis is being contemplated. Obviously, if a primary anastomosis can be accomplished, the disease can then be handled with a single operative procedure. If conditions exist to make the anastomosis hazardous, then a decision should be made for an end-colostomy and H a r t m a n n procedure. T h e concept of constructing an anastomosis about which the surgeon is wary and then doing a proximal colostomy to "protect" the anastomosis is fallacious. If that procedure is carried out, the patient still requires a second operation. W h y not then accept the fact that a primary anastomosis under those circumstances cannot be carried out properly and simply bring out the proximal colon as an end-colostomy, turn in the rectal segment, and then perform the second operation as soon as the sepsis subsides. Perhaps the single most i m p o r t a n t concept regarding perforation of a sigmoid diverticulum is to try :to avoid getting into that situation. Admitting that some papatients with free perforation have no ante-
DISEASE
295
cedent relevant history, most of the patients have had one or more episodes suggesting localized perforation as a sequela to diverticular disease of the colon. Rather than await the inevitable perforation with septic complications or perforation leading to obstruction, once the patient has had two or more bouts of obvious localized perforation, he should be advised to have an elective colectomy with primary anastomosis as the nleans of treating the diverticular disease before such a major complication as perforation occurs. If we use this somewhat more aggressive approach, the lnortality rate from diverticular disease should decrease, since there is no question that a standard left colectomy as an elective procedure is less hazardous than multiple procedures or even a single procedure done under emergency or urgent conditions. Dl~. GATHRIGHT T h a n k you, Professor Griffen. O u r final speaker is Dr. Robert Condon, Professor and Chairman of the D e p a r t m e n t of Surgery of the Medical College of Wisconsin in Milwaukee~ Dr. Condon will talk on the management of peritonitis and septicemia.
of Colonic Diverticula
WARD O. GRIFW':N, JR., M.D., PH.D.*
A major complication of diverticular disease of the colon is perforation of a single or several diverticula. T h e sequelae of the perforated diverticulum depend on the location and extent of perforation. A diverticulum situated on the antimesenteric border of the large bowel will most often produce free perforation into the peritoneal cavity. A diverticulum at the mesenteric border of the sigmoid colon may produce a localized process if the perforation is promptly contained, or with repeated or large perforations into the mesentery, the picture of bowel obstruction may be seen. When the perforation is free into the peritoneal cavity, there is immediate spillage of fecal material, and the patient usually has acute onset of lower or generalized abdominal pain. There may be no antecedent history suggesting diverticular disease. Depending upon the dtaration of symtoms, the findings will be those of generalized abdominal tenderness with rebound tenderness, at first local but later generalized. Bowel sotmds will be hypoactive or absent. Fever will be present, and an upright fihn of the abdomen may show free air under the diaphragm in approxi-
mately half of the cases. Obviously, the finding of free air under the diaphragm or progression of symptoms will make an exploratory celiotomy mandatory. T h e signs and symptoms associated with perforation into the mcsentery or quickly localized by adherence to the pelvic wall or lateral gutter are entirely different from those associated with free perforation. A small leak into the mesentery may manifest as mild left lower quadrant pain associated with anorexia, so-called "left-sided appendicitis." T h e physical findings are those of left lower quadrant tenderness, perhaps with some rebound tenderness and muscle guarding. Bowel sounds may be perfectly normal. T h e r e is usually some fever, the leukocyte count is elevated slightly, and flat and upright films of the abdomen are unremarkable. These patients frequently respond to bed rest, no oral intake, and systemic antibiotics. T h e y can then be evaluated for colonic disease after the symptoms have subsided. Obviously, if the patient's condition worsens despite this nonoperative therapy, exploration is mandatory. On the other hand, two different clinical pictures are associated with large contained perforations. T h e patient can have tile signs and symptoms of colonic obstruction, with a clear-cut history of several epi-
* D e p a r t m e n t of Surgery, University of Kentucky College of Medicine, Lexington, K e n t u c k y 40506.
293 Dis. Col. & Rect. 3/lay-June, 1976
Volume 19 Number 4
Dis. CoL & Rect. NIay-June, 1976
GRIFFEN
294
sodes of left lower q u a d r a n t pain and intermittent diarrhea and constipation, with a tendency to become more constipated until frank obstruction occurs. T h e r e is nsually left lower q u a d r a n t tenderness, a mass may be palpated, and rectal and sigmoidoscopic examination may demonstrate a lesion. Depending upon the duration of the obstructive symptoms, bowel sounds may be normal, the high-pitched tinkling sounds associated with obstruction, or absent. Little or no fever is present, and the leukocyte count may be normal or only slightly elevated. On the other hand, the patient may have developed a large abscess cavity in association with the perforation and be in an obviously septic condition, with abdominal pain, high spiking fever, a palpable left lower q u a d r a n t mass, and a probable mass on rectal examination. T h e leukocyte count usually is quite elewtted, and abdominal films may show evidence of an abscess. In either instance exploration must be performed. When an exploration is performed under any or the conditions outlined above, the surgeon is really faced with three basic decisions: 1) to drain or not to drain; 2) to divert or not to divert; and 3) to resect or not to resect. T h e m a n a g e m e n t of each patient should be individualized, but there are a n u m b e r of procedures that will suffice in a given situation. However, tile standard three-stage technique of right transverse colostomy for diversion followed by resection of the involved colon and primary anastomosis two, three, or even six months later, and finally closure of tlle transverse colostomy as three separate procedures should be used rarely, if at all. To
Drain
or N o t
to D r a i n
Obviously, if a patient has a localized abscess, it requires thorough and adequate drainage. If at all possible, it is best to provide for such drainage in an extraperitoneal fashion. It may be possible to
drain snch an abscess, particularly when there is pelvic extension, directly through the rectum or, in women, through the posterior fornix of the vagina. Conversely, it is impossible to drain the entire peritoneal cavity, and therefore drains should not be used when there is a free perforation of a diverticulum. W h e t h e r to use drains when a resection and primary anastomosis has been constructed is controversial. My own viewpoint is that under these circumstances drains are rarely necessary. To
D i v e r t or N o t
to D i v e r t
In the case of tile large abscess that requires drainage and in a patient who is quite ill, a quick loop colostomy of the descending or left transverse colon as a diversion may be the procedure of choice.. Diversion using the left colon proximal to tile obstruction 1nay be used in patients who are depleted and quite ill from tim obstructing process. In lnost other instances a proximal colostolny is no longer employed. To
Resect or Not
to R e s e c t
As preoperative preparation ol/ patients has improved, it is now possible in most instances of perforated diverticular disease where exploration is necessary to give the patient sufficient fluids and electrolytes, blood, and antibiotic intravenously so that he can withstand a major operative procedure. Tllerefore, resection is becoming the treatlnent of choice in lnany instances. In tile case of a free perforation, resection with an end-colosto,ny and oversewing of the rectal segment, the so-called " H a r t m a n n procedure," is the correct operation. Silnilarly, when the abscess is localized or there is obstruction without a great deal of abscess formation, resection of the involved segment with an end-colostomy and H a r t m a n n procedure may be utilized satisfactorily. T h e controversy surrounding resection under these circuln-
Volume 19 Number 4
MANAGEMENT
OF D I V E R T I C U L A R
stances is whether a primary anastomosis should be performed at the time of the resection. If there is any time when the patient must be handled individually, it is now, when a decision about primary anastomosis is being contemplated. Obviously, if a primary anastomosis can be accomplished, the disease can then be handled with a single operative procedure. If conditions exist to make the anastomosis hazardous, then a decision should be made for an end-colostomy and H a r t m a n n procedure. T h e concept of constructing an anastomosis about which the surgeon is wary and then doing a proximal colostomy to "protect" the anastomosis is fallacious. If that procedure is carried out, the patient still requires a second operation. W h y not then accept the fact that a primary anastomosis under those circumstances cannot be carried out properly and simply bring out the proximal colon as an end-colostomy, turn in the rectal segment, and then perform the second operation as soon as the sepsis subsides. Perhaps the single most i m p o r t a n t concept regarding perforation of a sigmoid diverticulum is to try :to avoid getting into that situation. Admitting that some papatients with free perforation have no ante-
DISEASE
295
cedent relevant history, most of the patients have had one or more episodes suggesting localized perforation as a sequela to diverticular disease of the colon. Rather than await the inevitable perforation with septic complications or perforation leading to obstruction, once the patient has had two or more bouts of obvious localized perforation, he should be advised to have an elective colectomy with primary anastomosis as the nleans of treating the diverticular disease before such a major complication as perforation occurs. If we use this somewhat more aggressive approach, the lnortality rate from diverticular disease should decrease, since there is no question that a standard left colectomy as an elective procedure is less hazardous than multiple procedures or even a single procedure done under emergency or urgent conditions. Dl~. GATHRIGHT T h a n k you, Professor Griffen. O u r final speaker is Dr. Robert Condon, Professor and Chairman of the D e p a r t m e n t of Surgery of the Medical College of Wisconsin in Milwaukee~ Dr. Condon will talk on the management of peritonitis and septicemia.
